Provider Demographics
NPI:1326057183
Name:BERARDO, NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:BERARDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JOHNSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-342-7353
Mailing Address - Fax:201-342-7982
Practice Address - Street 1:605 BROAD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657
Practice Address - Country:US
Practice Address - Phone:201-941-9494
Practice Address - Fax:201-941-1246
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD1144061223X0008X
NJ22DI01440601204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BE12759Medicare ID - Type Unspecified
T89831Medicare UPIN